NTSB Factual Report

HISTORY OF FLIGHT

On July 30, 2005, about 2120 eastern daylight time, a Cessna 172S, N65982, registered to MFH Leasing, Inc., operated by Epic Aviation, crashed in the Straits of Florida shortly after takeoff from Key West International Airport, Key West, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR part 91 personal flight from Key West International Airport (KEYW), to The Florida Keys Marathon Airport (KMTH), Marathon, Florida. The airplane was destroyed, and the commercial-rated pilot and three passengers were fatally injured. The flight originated about 2118, from Key West International Airport.

According to a transcription of communications with Navy Key West Approach Control, at 2118:45, an occupant of the airplane established contacted with their facility and provided the airplane registration number. The controller replied, "squawk zero two one zero wind one three zero at seven Navy Key West altimeter three zero zero four say type Cessna destination and requested altitude." The next comment was from the controller advising the pilot to say the type of aircraft, the destination, and again advised the transponder code was 0210. At 2119:21, an occupant of the airplane replied, "Squawking zero two one zero. It's a Cessna Skyhawk six five nine eight two. We like southbound to transition your airspace to the south on a cross country to Marathon, yeah." The controller again advised the pilot to "squawk" 0210, to which an occupant replied at 2119:48 "zero two one zero Cessna six five nine eight two." The controller advised the pilot that the "transponder not observed reset and squawk zero two one zero." The pilot did not reply and there were no further recorded transmissions from the occupant of the accident airplane. The controller attempted numerous times to communicate with the pilot; the results were negative. There was no recorded distress call made by the pilot.

According to the "Radar Supervisor/Approach Controller" at Navy Key West Terminal Radar Approach Control (TRACON), after advising the pilot a second time to apply discrete transponder code 0210, he waited a few scans of the radar but he was never able to radar identify the flight. Additionally, he did not see a primary target departing KEYW. He attempted to communicate with the airplane on VHF guard (121.5) and also UHF guard (243.0) frequencies but there was no response. Knowing the KEYW air traffic control tower was closed, he also attempted to establish contact with the pilot on the KEYW Common Traffic Advisory Frequency (118.2 MHz); there was no response.

Review of recorded radar data from Miami Air Route Traffic Control Center revealed there was no radar target associated with the assigned transponder code 0210. Two radar targets with beacon code 0201 were observed. The first radar target occurred at 2116:47, and the second target occurred at 2117:11, both were located over KEYW.

The controller who was talking with the pilot of the accident airplane contacted Miami Air Route Traffic Control Center (Miami ARTCC) about 2135, and questioned whether Miami ARTCC had established two-way communications with the accident airplane; the response was they had not. The controller also contacted fire rescue at Key West International Airport about 2145, and asked to have a ramp search performed. The individual reported that he advised the controller that the flight had departed at 2112, but a ramp check would be performed. Additionally, the Miami ARTCC reportedly established contact with personnel from KMTH, and requested a ramp search to be performed. Ramp searches were performed at KEYW and KMTH; the results were negative. On the evening of the accident, the U.S. Coast Guard was advised by the Monroe County Sheriff's Office of a report of a boater seeing a flash and hearing a loud sound. The U.S.C.G. dispatched a boat in the area and the crew of that boat later reported seeing lighting and hearing thunder from a nearby storm, but no wreckage was located. The following morning at approximately 0813, a boater contacted the U.S.C.G. and advised seeing a portion of one of the wings partially submerged. The U.S. Coast Guard contacted Monroe County Sheriff's office on July 31, 2005, at 0930, and requested underwater assistance with the aircraft wreckage. The wing was recovered and a search for the airplane and the occupants was then performed by the U.S. Coast Guard, Monroe County Sheriff's Office, U.S. Navy Police, Florida Fish and Wildlife Conservation Commission (FWC), and NOAA. The wreckage consisting of the fuselage was located on August 2, 2005.

PERSONNEL INFORMATION

The pilot was the holder of a commercial pilot certificate with ratings airplane single engine land, and instrument airplane, which was issued last on August 17, 2002. She was the holder of a first-class medical certificate issued on February 7, 2005, with the restriction or limitation "must wear corrective lenses." Her last "Flight Review" conducted in accordance with 14 CFR Part 61.56, occurred on July 27, 2005. The flight review was given by a flight instructor with Epic Aviation in a Cessna 172S.

The flight review consisted of 1.0 hour ground, and 1.4 hours of flight. According to the flight instructor who performed the flight review, the ground review consisted of airplane performance, systems of the airplane, review of speed, airspace, VFR weather minimums, and emergency engine procedures. The flight instructor stated that the pilot was "...found to be very knowledgeable on covered topics." The flight review was conducted to the commercial practical test standards, and consisted of steep turns, slow flight, power-on departure stall, and several touch-and-go landings.

NTSB review of the pilot's pilot logbook that contained entries from July 24, 1999, to the last entry dated July 27, 2005 (Flight Review), revealed her logged total time was 260.4 hours, of which 144.4 hours were as pilot-in-command. There were only 2 logged flights in Cessna type airplanes. Her total logged night time was listed as 9.4 hours. There were no logged flights between October 14, 2002, and the last logged flight on July 27, 2005. No determination could be made whether the pilot was current to fly at night.

A review of the application for the pilot's last medical certificate dated February 7, 2005, revealed she listed a total flight time of 900 hours.

AIRCRAFT INFORMATION

The airplane was manufactured by Cessna aircraft Company in 2004, as a model 172S, and was designated serial number 172S9766. The airplane was certificated in the normal and utility categories, and was equipped with a McCauley fixed pitched propeller, model 1A170E/JHA7660, and a 180-horsepower Lycoming IO-360-L2A engine. The airplane was also equipped with a two-axis autopilot with altitude preselect and two engine-driven vacuum pumps, which provide vacuum necessary to operate the attitude indicator and directional gyro.

A review of the airplane maintenance records revealed the airplane was last inspected in accordance with a "Phase II" inspection, which was signed off as being completed on July 29, 2005. The airplane had accumulated approximately 1.8 hours since the inspection at the time the airplane was rented by the accident pilot. Further review of the maintenance records revealed no entry indicating removal, replacement, or repair of the transponder.

At the time of rental by the accident pilot, the installed hour meter indicated 653.2. At the time of the accident, the hour meter indicated 656.9.

There was no record of fuel servicing or maintenance being performed to the airplane while at KEYW.

METEOROLOGICAL INFORMATION

A METAR weather observation taken at 2053, at Key West International Airport, or approximately 26 minutes before the accident, indicates the wind was from 100 degrees at 11 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dewpoint were 30 and 23 degrees Celsius, respectively, and the altimeter setting was 30.03 inHg.

On the day of the accident at 1647, the pilot phoned the Miami Automated International Flight Service Station (Miami AIFSS) and received a preflight weather briefing for a flight from KEYW to New Smyrna Beach Municipal Airport (KEVB), New Smyrna Beach, Florida. At 1952, the pilot again phoned the Miami Automated International Flight Service Station and obtained an abbreviated preflight briefing for a flight from KMTH to KEVB.

On the date, and area of the accident, the sunset was determined to have occurred at 2012, and the end of civil twilight occurred at 2037. The phase of the moon was waning crescent with 25 percent of the Moon's visible disk illuminated.

COMMUNICATIONS

The Key West International Airport (KEYW) air traffic control tower (ATCT) closed at 2100; and was not recording communications at the time the flight departed. A "Watch Log" which documents arriving and departing aircraft indicates that on the date of the accident at 2112, an airport fire department individual noted the flight departed.

According to the individual who prepared the entry in the "Watch Log", the time "2112" was based on a digital watch.

According to personnel from Key West Approach Control, their facility utilizes transponder codes that begin with 02, followed by two digits. On the night and time of the recorded 0201 radar targets, they had not assigned that transponder code to any aircraft. Approximately 2125, or approximately 7 minutes after the accident flight departed, another airplane (N122AW) departed KEYW and the pilot established contact with Key West Approach Control. There were no reported communication difficulties with that facility, and the airplane (N122AW) was radar identified. Additionally, there were no reported discrepancies related to the Key West Approach Control radar.

AIRPORT INFORMATION

The Key West International Airport is equipped with a one runway designated 09/27 which is 4,801 feet long and 100 feet wide.

Review of a security tape from KEYW Airport revealed the airplane was captured taxiing for takeoff, and a portion of the takeoff was also captured. The flight was determined to have departed at 2118.

WRECKAGE AND IMPACT INFORMATION

The right wing was the first piece of wreckage found on July 31, 2005, and was located at 24 degrees 33.7 minutes North latitude, and 081 degrees 43,0 minutes West longitude. The fuselage was located on August 2, 2005, at 24 degrees 32.323 minutes North latitude, and 081 degrees 42.719 minutes West longitude, in 27 feet of water. The fuselage was inverted on a heading of 310 degrees, and the empennage was bent approximately 90 degrees to the right. The engine with attached propeller, firewall, and instrument panel were located on August 5, 2005, at 24 degrees 41.012 minutes North latitude, and 081 degrees 41.897 minutes West longitude. All observed/located wreckage was recovered for further examination.

Examination of the wreckage revealed the left wing was separated and not located, and the right wing was separated at the wing root. The airframe structure from the instrument panel forward, and the cabin roof were separated. The cabin floor was displaced up approximately 2 feet between the main gear attach point and the aft cabin bulkhead. The vertical stabilizer remained attached to the airframe, and the rudder remained attached to the vertical stabilizer. Both horizontal stabilizers were structurally attached, and both elevators remained attached to both horizontal stabilizers.

The left elevator was partially separated at midspan; the elevator was bent up nearly 180 degrees. The tip of the right elevator was displaced up. The elevator trim tab actuator measured 1.6 inches extended, which equates to 15 degrees trailing edge tab up. The left horizontal stabilizer was rotated down approximately 90 degrees, and aft crushing was noted. The right horizontal stabilizer tip was rotated down, and the full span of the leading edge was damaged.

The empennage was displaced to the right, and compression wrinkles were noted on the right side of the empennage. Examination of the separated right wing revealed the main spar was still attached to the carry-thru which was fractured mid-span. The rear spar attach point was pulled from the wing. The full span of the flap was installed, and the flap actuator indicated the flaps were retracted. Both flap cables were attached to the flap actuator. A section of aileron remained connected at the inboard and middle hinges; the aileron separated in the area of the bellcrank. Both aileron cables were connected to the right aileron bellcrank near the control surface, but both exhibited evidence of tension overload in the wing root area. Full-span leading edge damage was noted, and the main spar was rotated down approximately 180 degrees beginning about 1/3 span. Both cables for autopilot roll were connected to the roll servo; the capstan was noted to move freely.

The fuel strainer bowl was separated; the screen had white colored debris adhering to it. Both main landing gear wheel assemblies were separated from the axles; the bearings were missing. The nose landing gear strut was separated from the nose landing gear strut housing. Both aileron control cables were connected in the cockpit, but exhibited tension overload in the wing root area. Rudder control cable continuity was confirmed. Elevator control cable continuity was confirmed for one of the cables, but the other cable was fractured near the bellcrank in the cockpit; no evidence of preexisting failure was noted on the fractured cable. No evidence of fire or soot was noted on any recovered component.

Examination of the separated instrument panel revealed the clock was destroyed, and the airspeed indicator was reading off scale low (the needle moved freely). The vertical speed indicator indicated a descent of 2,000 feet-per-minute. The attitude indicator indicated a 30 degree nose low, and approximately 120 degree right bank. The directional gyro was indicating 270 degrees, and the electric turn coordinator was destroyed. The tachometer, fuel gauges, vacuum gauge, CHT gauge, oil temperature gauge, and amp meter were missing and not recovered. The throttle and mixture controls were in the full open, and full rich positions, respectively. The flap selector was at 10 degree extension, while the flap indicator was at 30 degrees. The cabin heat was off, and the cabin air was closed. The hour meter indicated 656.9. The horns of the pilot's control yoke were not fractured, while the right horn on the co-pilot's control yoke was fractured. The autopilot circuit breaker was in an open position. The transponder remained secured to the mounting rack but the mounting rack was separated from the instrument panel. The transponder, directional gyro, and attitude indicator were retained for further examination.

Examination of the engine revealed impact damage to the left and bottom side of the engine, and the No. 2 cylinder exhibited impact damage including separation of the front pushrod. Additionally, the No. 2 cylinder injector nozzle was broken. The propeller remained secured to the engine. Compression was noted in all cylinders during hand rotation of the crankshaft. Crankshaft, camshaft, and valve train continuity was confirmed with the exception of the missing No. 2 cylinder forward pushrod. The servo fuel injector (fuel servo) and mechanical fuel pump were separated but recovered. Examination of the fuel servo revealed the control connections were broken, and the inlet screen was separated and not located. Partial disassembly of the fuel servo revealed salt water and aviation fuel were present. Examination of the flow divider revealed the spring was not failed, and the valve piston was free to move. There were no obstructions of the flow divider, fuel injector lines, or fuel injector nozzles. The mechanical fuel pump was impact damaged; the top of the unit remained secured to the accessory case, while the lower portion was separated but recovered. Examination of the top of the mechanical fuel pump revealed the internal steel parts and diaphragm were not failed.

NTSB Probable Cause

The failure of the pilot-in-command to maintain directional control of the airplane during the dark, night flight over water, resulting in the uncontrolled descent and in-flight collision with the water. A contributing factor in the accident was the pilot's distraction with the inappropriately set transponder.